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Case

presentation
Tuberculosis
Anouk Claessens
Oryza Tjoa

Contents
!

Identication

Anamnesis

Physical examination

Laboratory ndings & other diagnostics

Conclusions & dierential diagnosis

Plans and treatment

Discussions

Identication
!

Girl, 4,5 years old

G1P0A0, a term, normal prenancy & birth


(no maternal infections, no complications)

BW/A: -2-0 SD, L/A: -2-0 SD, BW/L: -2-0 SD

Vaccination status: BCG, DTP (1-3), polio (1-3), hepB (1-3), campak

No previous illness

Anamnesis (1)
History
! Since 18 days productive cough, subfebril fever, noctural sweating and a
cold.
! Midwife drug (?)
! Doctor: general complaints allergic cough drug (?) no eect
! 12 hours before admission: hemoptoe 2 spoons, subfebril fever,
dyspnoe (-) ER
! 17.08.2014: RSMH
! Contact TB: (+) -> aunt treated for TB 5 years ago. Now suspicious for
relapse, same room with child.

Anamnesis (2)
!
!
!
!
!

F (-), noctural sweating (+)


Aunt: atmitted 19.08 in hospital,
suspicion of TB
Cough (+), hemoptoe (-)
No artritis / joint pains
Dypnoe (-), chestpain (-)

Present (20.08)

5 points (max.) on international score



5 point (max.) on indonesian score
(family history, prolonged fever, chronic cough)

Score

points

Positive TB skin test

Large painless lymph nodes

Unexplained fever, night sweats, 2?


no response to malaria
treatment

Malnutrition, not improving


>4weeks

Length of illness <2 weeks

2-4 weeks

>4 weeks

Angle deformity of the spine

Joint/bone swelling or sinuses

Weight for age

>80%

60-80%

<60%

Familie TB (past

none

Reported by Proved
family
sputum +

Unexplained abdominal mass of


ascites
CNS: change in temperatment,
convulsions or coma

Score

or present)

Physical examination
On admission
! Sens.: alert
! BP: ?, P: 108/min, T: 36.9, RR: 28/min
! L:99cm, BW:14kg
! Head: eyes: not sunken, conjunctivae: not anemic, sclerae: non-icteric,
mucosa: wet.
! Thorax: symmetrical, no retractions
! Cor: S1S2, S (-), G (-)
! Pulm: inspection, percussion normal, vesicular (L>R), R (-), W (-)
! Abd: normal inspection, normal tympany and ausculation, no defense
! Extr: warm acra, CRT <3s

Physical examination
Present (20.08)
! Sens.: alert
! BP: ?, P: 98/min, T: 37.0, RR: 26/min, SpO2 98% (without oxygen)
! Head: eyes: normal, conjunctivae: not anemic, sclerae: not icteric, mucosa: wet,
no lymphadenopathy
! Thorax: symmetrical, no retractions
! Cor: S1S2, S (-), G (-)
! Pulm: inspection and percussion normal, vesicular (+) N, R (-), W (-)
! Abd: normal inspection, peristalsis N, normal tympany and ausculation, no
defense
! Extr: warm acra, CRT <2s

Laboratory ndings
19.08.2014
17.08.2014

Hb

15,2 g/dl

Hb

14,2 g/dl

AST

25 U/L

Leucocytes

23.900 /mm3

ALT

15 U/L

Platelets

499.000 /mm3

Albumin

4,5 g/dl

Ht

41 %

Ureum

24 mg/dl

Di. count

0/4/0/26/64/6

Kreat

0,32 mg/dl

CRP

< 5

Ca 2+

9,8 mg/dl

Na +

143 mEq/L

K +

4,7 mEq/L

IgM S. Typhi

Negative

Elevated Hb / Normal HT / Normal Alb -> (-)


Elevated WBC -> infection
Elevated platelets -> infection / blood loss ?
Neutropenie + lymfocytose -> infection ?
Normal CRP!

Other diagnostics
! Sputum smear / culture: 18.08 19.09 20.08
(no results yet)
! Gastric lavage + culture: not needed
! Urine / blood culture: no results yet

! X-thorax: intepretation radiology follows

Consultations:

ENT: epistaxis? -> no.


Conclusion & DD
4,5 years old girl with subfebrile fever, noctural sweating, productive cough,
haemoptoe and positive TB contact, admitted 4 days ago, now progressing
clinically but TB status unknown.

Dierential diagnosis haemoptoe + fever


Tuberculosis
Thyphoid fever
Malaria
(Broncho)pneumonia
DHF
Bronchustumor
Lungembolia
Vasculitis
Epistaxis

Plan & Treatment


Ambroxol 3x 7,5 g
viscid or excessive mucus
Ampicilin 3x500mg
suspect infection
Gentamycin 2x35mg
suspect infection
Clinical progression -> stop?

Tranexamat acid 3x140 mg (2 days) prevention excessive blood loss
Waiting for results of sputum / urine / blood culture
Waiting for results of X-Th interpretation

THANKYOU!!
BEDANKT !!
TERIMA KASIH!!